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1 Advanced E/M Auditing:The Secrets to Success2013 AAPC2480 South 3850 West, Suite BSalt Lake City, Utah 84120800-626-CODE (2633), Fax WorkshopsAdvanced E/M AuditingSecrets to SuccessBy Angela Jordan, CPCii AAPC 1-800-626-CODE (2633) CPT copyright 2012 American Medical Association. All rights Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. Readers are responsible to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course.

2 This guide is a general summary that explains guide-lines and principles in profitable, efficient health care organizations. US Government RightsThis product includes CPT , which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the Ameri-can Medical Association, 515 North State Street, Chicago, Illinois, 60610. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software docu-mentation are subject to the limited rights restrictions of DFARS (b)(2) (November 1995), as applicable, for Depart-ment of Defense procurements and the limited rights restrictions of FAR (June 1987) and/or subject to the restricted rights provision of FAR (June 1987) and FAR (June 1987)

3 , as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal DisclaimerCPT copyright 2012 American Medical Association. All rights schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT , and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not directly or indirectly prac-tice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical responsibility for the content of any National Correct Coding Policy included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied.

4 The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product. About the Author:Angela Jordan, CPC, is a Managing Consultant with Medical Revenue Solutions in Oak Grove, Missouri. Prior to joining MRS Angela worked as a coding and compliance manager for EvolveMD and HCA. She has been involved in consulting engagements associated with EMR implementation with provider and staff support. She provides reviews of CPT , ICD-9-CM, medical record documentation, billing, and compliance issues.

5 Her experience includes; family practice, internal medicine, pediatrics, neurology, OB-gyn, radiology, inpatient, outpatient, and other specialties. Angela is also very active in her support of the AAPC and their members. She is the current AAPCCA Board of Directors chair and is a past-president of the Kansas City Missouri chapter. Notice Regarding Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC preserve the real world quality of these notes for educational purposes, we have not rewritten or edited the notes to the stringent grammatical or stylistic standards found in the text of our products.

6 Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting. 2013 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, rights , CPC-H , CPC-P , CIRCC , CPCOTM, and CPMATM are trademarks of E/M Auditing Secrets to Success iiiContentsContentsWhy E/M Auditing? ..1 Keys to Success ..1 Knowing the Pieces ..1 Where Does Your Practice Fit? ..2 AAPC Physician Services ..3 The 20 Most Common Coding and Documentation Errors ..4 The Grey Areas.

7 Or Bad? ..7 Tips and Tools for Conducting an Internal audit ..9 Recommended Resources: ..16 Glossary: ..16 Case Studies ..17 CASE STUDY #1 ..17 CASE STUDY #2 ..20 CASE STUDY #3 ..21 CASE STUDY #4 ..22 CASE STUDY #5 ..24 CASE STUDY #6 ..27 Encounter form Diagnosis List ..28 Appendix ..31 NGS E/M Tool ..31 Novitas audit Tool ..37 Preventive Services Educational Products ..41 Quick Reference Charts ..43 HCY Screening Guide Instructions and form ..60 audit Development Letter ..65E/M audit Checklist Tool ..66 Slide Presentation ..71 Advanced E/M Auditing: Secrets to SuccessAdvanced E/M Auditing Secrets to Success 1 Why E/M Auditing?

8 Why is auditing so important, especially of Evaluation and Management (E/M) services? It is common knowledge that E/M services have been a favorite auditing target for years. They are frequently the focus of Comprehensive Error Rate Testing (CERT) and recovery audit contractor (RAC) audits, and E/M services always find a place on the annual Office of Inspector General (OIG) Work Plan. However, it was the May 2012 report Coding Trends of Medicare Evaluation and Management Service (OEI-04-10-00180) released by the OIG that grabbed a great deal of attention. Below is the summary from the May 2012 OIG report with findings and We Did the Study Between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent, from $77 billion to $110 billion.

9 During this same time, Medicare payments for evaluation and management (E/M) ser-vices increased by 48 percent, from $ billion to $ billion. E/M services have been vulnerable to fraud and abuse. In 2009, two health care entities paid over $10 million to settle allegations that they fraudulently billed Medicare for E/M services. CMS also found that certain types of E/M services had the most improper payments of all Medicare Part B service types in 2008. This report is the first in a series of evaluations of E/M ser-vices. Subsequent evaluations will determine the appropriateness of Medicare payments for E/M services and the extent of documenta-tion vulnerabilities in E/M services.

10 What We FoundFrom 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. Among these physi-cians, we identified approximately 1,700 who consistently billed higher level E/M codes in 2010. Although these physicians differed from others in their billing of E/M codes, they practiced in nearly all States and repre-sented similar specialties. The physicians who consistently billed higher level E/M codes also treated beneficiaries of similar ages and with similar diagnoses as those treated by other We RecommendCMS concurred with our recommenda-tions to (1) continue to educate physicians on proper billing for E/M services and (2) encourage its contractor to review physicians billing for E/M services.